The concepts of bonding and the
relation with tuberculosis control
*AS CONCEPÇÕES DE VÍNCULO E A RELAÇÃO COM O CONTROLE DA TUBERCULOSE
LOS CONCEPTOS DE ENLACE Y LA RELACIÓN CON EL CONTROL DE LA TUBERCULOSIS
* Extracted from the thesis “Avaliação do desempenho das Equipes de Saúde da Família no controle da Tuberculose no município de Bayeux - PB: o vínculo e o processo de trabalho na Atenção Primária à Saúde”, Federal University of Paraíba, 2007. 1 Nurse. Nursing Master Graduate. João Pessoa, PB, Brazil.
annaenf@gmail.com Nurse. PhD in Nursing. Professor of the Medical-Surgery Nursing and Administration Department at Federal University of Paraíba. João
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RIGINAL
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TICLE
RESUMO
O estudo analisa as concepções de vínculo que norteiam as práticas das Equipes de Saúde da Família (ESF) com relação às me-didas de controle da Tuberculose (TB) no âmbito da APS, no município de Bayeux – PB/Brasil.Mediante abordagem qualitati-va, envolveu 37 profissionais de saúde, sen-do os dasen-dos coletasen-dos pela técnica de gru-po focal em abril de 2007 e analisados con-forme análise de discurso. As concepções das ESF sobre vínculo revelaram coerência com os conceitos teóricos estudados, sen-do evidenciadas, na relação equipe/sen-doen- equipe/doen-te, confiança, compromisso, intimidade, e responsabilidade. Aspectos potencializado-res do vínculo: o tempo de atuação da ESF na comunidade; número de consultas e vi-sitas domiciliares e envolvimento com o controle da TB. Fragilidades no vínculo: in-suficiência de medidas intersetoriais, situ-ação sócio-econômica do doente e aban-dono da família. Ressaltamos a necessida-de necessida-de mudanças que fortaleçam a relação ESF/doente, e que, desse modo, concretize um cuidado fundamentado na integralida-de no cotidiano dos serviços integralida-de saúintegralida-de.
DESCRITORES
Tuberculose/prevenção & controle. Saúde da família.
Atenção primária à saúde. Equipe de assistência ao paciente
Anna Luiza Castro Gomes1, Lenilde Duarte de Sá2
ABSTRACT
This study analyzed the concepts of bond-ing that guide the practice of Family Health Program (FHP) teams in terms of tubercu-losis (TB) control measures in the public health setting, in the city of Bayeux, Paraíba, Brazil. Using a qualitative approach, the study involved 37 health care profession-als. Data collection took place using the fo-cal group technique, in April 2007. Data analysis was performed based on discourse analysis. It was observed that FHP team concepts about attachment were in agree-ment with the studied theoretical concepts, with evidences of trust, commitment, inti-macy, and responsibility in the team/pa-tient relationship. The following aspects strengthen the bond: the time that FHP teams work in the community; the number of home visits and consultations and the involvement with TB control. Bond weak-nesses: insufficient intersectorial measures, the patient’s socioeconomic situation, and family abandonment. It is emphasized that there is a need for changes that would strengthen the relationship between the FHP team/patient. This way there would be a concrete care founded on the integrality of health care service routine
KEY WORDS
Tuberculosis/prevention & control. Health family.
Primary attention to health. Patient care team.
RESUMEN
El estudio analiza las concepciones de vín-culo que orientan las prácticas de los Equi-pos de Salud de la Familia (ESF) con rela-ción a las medidas de control de la Tuber-culosis (TB) en el ámbito de la APS, en el municipio de Bayeux–PB/Brasil.Mediante un abordaje cualitativo, en que participa-ron 37 profesionales de la salud, siendo los datos recolectados por la técnica de grupo focal, en abril de 2007 y analizados confor-me el análisis del discurso. Las concepcio-nes de las ESF sobre el vínculo revelaron coherencia con los conceptos teóricos es-tudiados, siendo evidenciados, en la rela-ción equipo/enfermo: confianza, compro-miso, intimidad, y responsabilidad. Aspec-tos de potenciación del vínculo: el tiempo de actuación de la ESF en la comunidad; número de consultas y visitas domiciliares, participación en el control de la TB. Fragili-dades en el vínculo: insuficiencia de medi-das intersectoriales, situación socioeconó-mica del enfermo, abandono de la familia. Destacamos la necesidad de efectuar cam-bios que fortalezcan la relación ESF/enfer-mo y de ese ESF/enfer-modo, concretice en lo coti-diano de los servicios de salud, un cuidado fundamentado en la integralidad.
DESCRIPTORES
Tuberculosis/prevención & controle. Salud de la família.
INTRODUCTION
The concept of bonding is polysemous. It encompasses both the social sciences and the health science areas, as-suming several approaches, such as: dimension, guideline, strategy, technology, purpose and relation. In addition, it presents an interface with other well-known concepts in public health such as those of humanization, user embrace-ment, responsibility, integrality and co-administration.
Bonding connects people, indicates interdependence, relations with double meaning lines, and the commitment of the professionals towards users and vice-versa (1). It is
dependent on the manner in which health care teams take responsibility for the health of the group of people living in a certain micro-region. Furthermore, the bond of the popu-lation with the health unit requires the establishment of strong interpersonal ties that reflect the mutual coopera-tion among the people in the community and the health professionals(2).
Bonding is still considered a dimension of Primary Health Care (PHC) and presupposes the existence of a regular care source and its use over the years(3). Thus, it is recognized
that the primary health care unit constitutes:
the first contact level of the family and community individu-als with the national health system, taking the health care as close as possible to the place where people live and work, constituting the first element of a process of
contin-ued health care(2).
In Brazil, there is a national proposal of investment in PHC that aims to reorganize the model of health care and services based on the daily bonding with the population. This bonding has the function of enabling a health care sys-tem that strengthens the care relation dimension and al-lows a broader approach of the Single Health System (SHS) towards the population needs(4). In this perspective, the
humanization policy of the SHS stands out, established
as the construction/activation of ethical-aesthetic-political attitudes in tune with a project of co-responsibility and quali-fication of bonding among professionals and between
pro-fessionals and users of the health care system(5).
From the perspective of PHC, there must be an intimate relationship between bonding and the other dimensions that encourage its success, such as the access, the entrance door, the casting of services, the family focus, the guidance for the community and the professional development and coordination. Nowadays, in Brazil, the strategy of Family Health (FH) is considered a thriving modality of the PHC that, together with the Health Community Agent Program (HCAP), are responsible for the development of TB control actions in this health care area(6).
Therefore, the organization of the FH strategy promotes the production of bonds between health professionals and persons with TB, since the FH units favor the first contact
of the communities with the service, which allows the Fam-ily Health Teams (FHT) to adapt themselves to the different needs of the community under their responsibility; this promotes a closer and longer relationship between the health services and the users of these services. The national guidelines for disease control are currently operated by the FHT through the Directly Observed Treatment Short-Course (DOTS), which reinforces the decentralization policy of the services established by the SHS(7).
The DOTS strategy has been considered successful due to the positive change in TB cure rates, since it contributed to both abandonment and mortality reduction. In addition, DOTS allows the participation of the user with TB as a sub-ject in the therapeutic process, a fact that promoted the con-struction of bonds between users and health professionals through the establishment of a relationship of trust, affinity, responsibility and mutual commitment(7). However, even
though this strategy has shown success in cities where TB control actions were decentralized by the PHC, the disease is still a serious public health problem, since its prevalence has increased because of its association with HIV and its resis-tance to drugs due to the issue of treatment abandonment(8).
Twenty-two countries around the world are responsible for 80% of the diagnosed cases of tuberculosis. Brazil stands in 16th place on this list, with an incidence of 28 cases
(posi-tive baciloscopy) per 100,000 inhabitants, a prevalence of 92 per 100,000 inhabitants, a co-infection rate with Human Immunodeficiency Virus (HIV) of 3.8% and cases of multi-drug-resistant (MDR) tuberculosis of 0.9%(6). In the
Brazil-ian scenario, Paraíba has the 13th highest incidence of TB
cases(9), a situation that made the Health Department elect
six important cities for the control of the disease in this state: João Pessoa, Bayeux, Santa Rita, Campina Grande, Patos and Cajazeiras(10). The first three cities are located in
a region named Zona da Mata, and are part of the metro-politan region of João Pessoa – capital of the state. Campina Grande belongs to the region of Borborema. Patos and Cajazeiras are located in the area known as Sertão.
The social and economic reality of each city in Paraiba, the political commitment of each administrator and the in-volvement of professionals in tuberculosis control deter-mine the heterogeneity of the epidemiological character-ization and influence the way the relationship between FHT and persons with TB is established. In this context, this study considers that the establishment of bonds provides a thera-peutic resource that determines the way teams take respon-sibility for the health of the group of people under their supervision, and on their involvement according to the singularities of each case(1). Furthermore, it is important to
highlight that the notion of integrality as a SHS principle must guide professionals to listen, comprehend and then meet the demands and needs of the people, groups and communities in a new health care paradigm(11).
in Bayeux – PB/Brazil, recognizing that TB combat actions assume different formations due to the singularities of the individuals and scenarios, and that the patient care, from the integrality perspective, requires the establishment of a relationship of trust and commitment among the people involved in the therapeutic process.
METHOD
Study type
This exploratory and descriptive study uses a qualita-tive approach. At first, the field to be studied was observed during the entire month of March, in 2007, with the pur-pose of understanding the primary health care services in the city of Bayeux – PB/Brazil, as well as the operation of DOTS strategies by the local FHT. The theoretical-method-ological reference is based on the concept of bonding as a PHC dimension (2) and on the discourse analysis technique,
which aims to identify the world view of a certain social class and the social position of the subjects, through themes and figures shown in statements(12).
Study location
Bayeux was the elected study location. It belongs to the 1st Regional Health Center of Paraíba, and is located in the
micro-region of João Pessoa – PB, having the cities João Pessoa and Santa Rita on its respective east and west bor-ders. According to The Brazilian Institute of Geography and Statistics (IBGE), its population was estimated at 95,004 inhabitants in 2006. This city has been determined to be under the full administration of systems since 2003, and has 28 FHTs that are responsible for the operation of DOTS in TB cases. Bayeux also has two polyclinics, one maternity clinic, where the BCG vaccine is applied, one city lab, re-sponsible for the control and diagnostic baciloscopies and five centers for sputum collection, one per health district.
Studied population
The study included the participation of professionals from 16 FHTs that, up to March 2007, had been monitoring persons in treatment for TB. There were five doctors, thir-teen nurses, thirthir-teen nursing assistants and six health com-munity agents (HCA). The participants were coded with al-phabetical letters and Arabic numbers in order to guaran-tee their anonymity, as well as to meet the requisites pro-posed by the Resolution 196/96, which sets regulations and guidelines for studies involving human beings(13).
Data collection technique
Seven focus groups were formed, with six to twelve par-ticipants per group. The meetings took place between April 24 and May 08 in 2007, at the Human Resources Development Center (Centro de Formação de Recursos Humanos -CEFOR) of Bayeux – PB, and each one of them took ap-proximately 2 hours. Discussions in the focus groups were
led by the researcher, according to a script previously con-structed with the following guiding questions: How does the team take care of the TB patient and his/her family? What are the difficulties encountered by the team in car-ing for the TB patient and his/her family? What is the na-ture of the relationship between the team and the TB pa-tient? What is the nature of the relationship between the team and the TB patient’s family? What is the nature of the relationship between the team and the community in their covered area?
Data was collected using a voice recorder and spread-sheets for the recording of relevant points, determined by the observers. The criterion used to select these observers was the condition of belonging to the TB/PB Group - Group of Studies and Qualification in Tuberculosis of Paraíba (Grupo de Estudos e Qualificação em Tuberculose da Paraíba – GRUPO TB/PB). The discussion was encouraged through the presentation of three situations involving FHT actions in TB patient care and preceded by the stages of participants’ introduction, explanation of the meeting pur-pose, and reason for using a voice recorder, as well as an explanation of confidentiality of the obtained information, according to the description of the project approved by the Ethics Committee of the Health Science Center from the Federal University of Paraíba - CCS/UFPB, under the proto-col number 936/07.
Data analysis technique
The recorded statements were transcribed and orga-nized according to the guiding questions, using the dis-course analysis technique, which allowed the identification of the concepts FHT professionals have regarding bonding and how these concepts influence their practice regarding the care of people with TB. The analysis of the produced empirical material allowed the summarization of the sub-jects of the statements into two empirical categories: the bonding conceptss and the involvement of the FHT with TB
patients and their families; and aspects thatweaken the
bonding between the FHT and the TB patient.
RESULTS AND DISCUSSION
The bonding conceptions and the involvement of the FHT with TB patients and their families
After analyzing the material produced by the discussions in the focus groups, it was possible to identify the involve-ment of FHT professionals who are directly responsible for the operation of DOTS in Bayeux - PB. The discussion also allowed the identification of concepts about bonding, in-tegrality, responsibility of the care given to the TB patient, FH strategy, operation of TB control actions in the PHC scope and work relations existing in the FHT. The results produced during the discussion will be presented as follows.
in a certain micro-region. The FH strategy is currently consid-ered as a powerful strategy in the PHC scope for promoting the construction of bonds between professionals and persons with TB, since the Family Health Units (FHU) are responsible for the identification and treatment of these persons , consti-tuting the first access to the SHS. A nurse admitted:
We are with that patient every day. We know how to recog-nize when he is a little sad or concerned. Then we some-times talk, and the patient opens himself up to us (E12).
Regarding the bonding concepts presented by the FHT, a prevalence of the theorized ideas of connection and link was observed, according to the following statement:
It’s a link, a connection, intimacy [...] it becomes even a friendship relationship, between the patients and us. They trust us very much (TE10);
Bonding is a kind of dependence, a connection that you may have with something, a link (M4).
Professionals also associated the bonding concept with relationships that involve trust, affinity, commitment and responsibility, as a participant stated:
I understand bonding as the trust the patient acquires with the health professional for stating his problem, and not be-ing ashamed to tell it. [...] a trust relation [...] They trust us. We make them feel safe, we guide them (TE6).
Regarding the bonding meaning, an interesting fact was that some professionals relate it to the care concept, as it may be observed in the statements of an HCA:
It is a care bonding, it is about becoming a friend of the patient and knowing by heart whatever it is that you have to say about him. That is bonding for me (ACS4);
and a nurse, whose conception of bonding is close to the integrality discourse:
It is about knowing the patient’s story, treating them well and making them feel at home. I believe that is bonding (E12).
This conception suggests the broadening and develop-ment of care in the health profession, in order to form pro-fessionals who are more responsible for the results of care practices, more capable of creating a bond with the health service users and embracing them, as well as more sensi-tive to understanding the health/disease process registered in the epidemiology or therapeutics areas(14).
The exercise of integrality constitutes an intersubjective practice, in which the health professional relates to a sub-ject who thinks, feels, judges, and wishes. In other words, health professionals must develop intersubjective relation-ships, in which the health care user assumes the condition of subject rather than object(15). This means teams must
know/identify the users’ needs so that they can understand and support the situations they experience. The reference to the need to know the story of the subject shows that this happens from the knowledge and
identifica-tion of some aspect of this subject, involving approach, inti-macy, interest in this person and affinity. In this context,
the bonding allows a more effective approach between health care user and professional, at times even leading to a transfer process, in which the professional starts to rep-resent someone of importance in the patient’s life, as well
as the patient in the professional’s life(7).
It is also recognized that the bonding process means the establishment of strong interpersonal ties that reflect the mutual cooperation between the community people and health professionals through the processes of listen-ing, dialog and respectful relations, in which the patient comes to understand the meaning of the care he is given and his co-responsibility in this process (3). In this manner ,
the bonding allows health professionals to meet the needs, to advise, to share opinions, and to promote psychological support; in other words, it allows them to push the devel-opment of actions aimed at the relief of the patient’s anxi-eties, needs and pain.
It is worth highlighting that the stigmatizing character of tuberculosis and the unfavorable social conditions of most of the patients require the involvement and commit-ment of the FHT with these patients during the treatcommit-ment, since the impact caused by the disease on people’s lives is still very strong and may interfere in several dimensions of the human being: physical, social, psychological, economi-cal and spiritual. A nurse made the following statement regarding this idea:
He gets down, depressed and isolated from society; he becomes aggressive and suffers a series of changes in his behavior (E10).
From the perspective of the integrated care of the sub-ject, it is fundamental for health professionals to be more sensitive, listen to the other, and understand what he thinks, in an approach that cannot be distant or impersonal(1). The
knowledge of reality and the health care user’s life context is essential, considering that the health concept involves life quality, and that the latter is determined, among other as-pects, by the biological, psychological and social well-being. Therefore, the strengthening of bonds between users, fam-ily and community with the team may be considered to be a therapeutic resource and one of the most suitable means to have a clinical practice of quality(1). At the same time, the
ability of the team to take responsibility for the integral care of those who live in a certain territory must be considered as a basic condition for the bonding construction.
The possibility of identifying the needs demanded by users allows the establishment of a relationship of trust and responsibility with the team which, in the case of a person with TB, becomes essential to the production of bonding and, consequently, for the success of treatment . This reality may be evidenced by the following statement:
pro-important, because when we achieve this trust, we see re-sults in the treatment (E8).
In this context, it is noted that the FHT professionals’ behavior influences the way the patient is able to under-stand the disease, accept or abandon the treatment and move on with his life from that moment. This is why it is important that the teams are technically prepared to port and favor this process, being available always to sup-port so many needs, because the knowledge and mean-ings constructed and introjected by different subjects dur-ing their lives influence their actions.
Regarding the involvement with the disease control ac-tions, FHT professionals state that nursing professionals stand out mainly in the treatment supervision activities and search for missing patients:
[...] patients trust the professional a lot, mainly the nurse and the assistant who are close to him (TE6).
A nurse explains:
Whenever a TB patient arrives, they say: look for the nurse over there. It is only with her, you can look for the nurse for everything you need (E12).
The treatment supervision activities and search for miss-ing patients are fundamental for the control of TB, and re-quire the establishment of trust and intimacy between pa-tients and health professionals; in other words, the produc-tion of bonding relaproduc-tionships are crucial for the success of the therapeutic process. Besides, such activities favor the identifi-cation of the patient with TB and the conclusion of the dis-ease treatment, and require the establishment of a trust and intimacy pattern between patients and health professionals; in other words, the production of bonding relationships.
According to the professionals’ statements, it was ob-served that the involvement with the DOTS operation, mainly the treatment supervision, has favored the construc-tion of bonds between the FHT and the patient, since the responsibility and commitment required from profession-als take them closer to the patient’s life context. At times, the patient is so wellsupported in the care relationship that this feeling of trust evolves into a greater feeling of passion or love, as may be observed in the following statement:
They may even fall in love, because once I had a patient
who fell for me […] Then he said: I am in love with you […]
(E13).
And further explains:
It is that bonding you created, you treated him so well that he grows fond of you, isn’t it? (E13).
The statements that follow were selected to demon-strate the trust patients with TB have in the FHT:
In my team, the relationship was great, this patient had so much trust in me that his wife and children looked for me as soon as they got to the unit (E3);
[…] in my community they listen to me. As I have been there for a long time, they respect everything I say alot (M2).
The next statements show how the bonding construc-tion is strengthened by other factors, such as the period of time the professional has worked in the community, the consultations and home visits, the trust relation established between the patient and the team and their contact:
[...] I created a bond. I have worked there for six years (M2);
Then when the patient realized I was worried about her case, she started acting differently with me. She arrives at the unit smiling, talking to me... there is an interaction be-tween patient and professional (E11).
Even though the presented concepts are close to the bonding concept on which this study is based, when it re-fers to a link, professionals articulate the bonding concept to that of integrality, humanization and user embracement. However, they also described situations that involve struc-tural, administrative and family aspects that may weaken bonding relationships, such as the demands of health care users, and the lack of interest of some professionals in the TB problem and situations that express vulnerability.
Aspects that weaken bonding between the FHT and the TB patient
Despite the fact that FHT defends a practice based on the caring approach of the TB patient and his family, and on their effective participation during the treatment, this study identified situations that weaken the relationships between these health care users and the FHT, and that com-promise the construction of bonds between them. There are situations, although rare , in which professionals do not even meet the patient, believing that this fact does not in-terfere in the care given by the team.
I didn’t have any contact with him. Maybe there is some-thing that I don’t know. Everysome-thing is ok for me. I don’t know so far (TE 8);
I have a patient who has been with us for four months and the doctor hasn’t met him yet (ACS 1);
The assistants, do I know them by their names? I don’t think so. We don’t have that kind of involvement. But they visit, you know? We are more often present, but they are aware of it. They don’t get involved like we do. It is gener-ally with the ACS, the nurses (E12).
The statements of the professionals are supported by a study developed regarding the involvement of primary health care teams in the control of tuberculosis in cities in São Paulo, in which the authors demonstrate the qualita-tive weakness of the health care professionals, indicating the quality of the professional-user interaction in handling the disease properly(16).
depen-dence and vulnerability situations – low income, unhealthy housing conditions, TB/HIV co-infection, malnutrition, im-migration and restricted access to basic rights such as health and education – have contributed not only to the increase in exposure and susceptibility, but also to the weakening of the relationship between user and FHT (17). These aspects
are even more significant when the patient abandons the treatment, since the bonding precariousness makes the patient’s achievement and his return to treatment more difficult.
I talked to him yesterday; he doesn’t want to stop drinking and he can’t stop drinking, because if he does, he has sei-zures all the time (E5).
Another nurse highlights the fragility of the interaction among the family, patient and FHT:
In my FHT, the relationship of our team with the family of this patient is very complicated. Because this family aban-doned the patient [...] we ask them to go to the unit but they won’t go. They don’t go. Not even his mother or his brother. We try through insistence and perseverance. The ACS stands at the door, because they won’t let him in (E6).
Another aspect to consider is that the medical profes-sional seemed to be the FHT member who was the least in-volved with the TB patient, as if he were behind the action. The distance between doctor and patient was emphasized at several points during the group discussions, since the per-formance of these professionals is particularly related to the biological and physical situation of either the disease or the treatment, such as clinical irregularities and drug reactions. Therefore, even though some doctors recognized that their relationship with TB patients was precarious, nothing was proposed to improve this situation and, once again, the
reification aspect of the patient was reinforced, as if the only
alternative they had was conformation:
Mine is horrible! (laughs). I am straightforward. It is be-cause I have seen the patient only once, the freak (M3).
The attitude of FHT professionals is highlighted when they are exposed to different behaviors of the patients , who are often aggressive and disrespectful with those who are in charge of their health and that of the community. Critical situations show the limitations of the profession-als, as well as the weakness of their relationships with these patients. The following statement presents an extreme situ-ation of ineffective bonding with a TB patient:
I escaped from being hit by him several times. Fifteen days ago, I think, he did it. My God! He started to offend every-body. Then I left and said: - ‘No! Let me out, he will hit me! He is a big man!’ The health agent who supervises the unit every day was verbally threatened, physically assaulted, and I notified the coordination, just because I didn’t know what else to do. Actually, I don’t know what to do. He gave up again (E1)
A person from the lab treated the inconvenient patient… he came back to me and he looked like a mentally disabled
patient, he almost hit me. He came back mad, he would have hit me because of what happened in the lab if my agent wasn’t there, who is 1.8m tall (E9).
This study showed the impotence of the team in terms of managing situations in which the patient does not rec-ognize neither his limits as a citizen, nor the rights of the health professional. It seems that FHT professionals are hostages of a fragile social control that has not managed to force the State to comply with its constitutional duties, even though they vehemently demand that health profession-als provide answers that they are not able to give. After all, given the health/disease process’ complexity and the unfa-vorable situation experienced by a great proportion of the Brazilian population, particularly TB patients, health poli-cies establish the need for coordination among the several areas of society aimed at promoting life quality.
In addition, a quality health care system requires a new process and working conditions with emphasis on the human-ization of the relationship between professionals and health care users – citizens suffering, with risks and rights, who hu-manize health professionals, also as citizens with rights(18). It
must be considered that civil servants become citizenship in-stitutors as soon as they take on the job, whose results are the
citizenship rights of everyone, including the servants, since
people take care of people in the health area(18).
Therefore, the bonding process may promote a new logic in the FHT working process, allowing care to be given from the prospective of integrality, so that health services begin to consider the user as the subject of his own thera-peutic process, and value his autonomy, feelings and needs. In this context, health care user embracement, bonding and responsibility are recognized as integral practices in the strategies of access improvement and development of in-tegral practices. The value of these aspects gives origin to
a formulation exercise of an operational definition of inte-grality as a democratic way to behave, of knowing how to integrate, in a care system that is based on an ethical-po-litical commitment relationship of sincerity, responsibility and
trust(15).
It is also worth highlighting that the commitment and co-responsibility bonding concept was proposed to the FHT, aimed at achieving strategic purposes such as: helping the transformation of the hospital-centered biomedical model into a social and health production model at the PHC level, broadening the responsibilities of professionals and users in the administration of health services and humanizing health care practices(16). Thus, the practice performance can
only achieve integrality by the effective exercising of team work, by embracing health care users, by establishing bonds with the responsibility regarding a health problem, and by relating to them as integral subject-citizens, with rights and abilities to participate and to be the subject of their own therapeutic process.
of quality and efficacy in the TB control actions in the PHC area. The situation requires the adoption of intersectorial measures by the local administration, a greater involvement of the family and medical professional with the DOTS op-eration, and the improvement of FHT working conditions and changes in the working process of the teams, in order to strengthen the relations of trust and commitment exist-ing so far.
FINAL CONSIDERATIONS
This study showed that FHT concepts about bonding present relations with the concepts of integrality and hu-manized care, which reinforces the polysemous character of the term. The meaning attributed to bonding showed
the prevalence of the ideas of connection, approach, inti-macy and involvement, as well as the cohesiveness with the bonding concept of the PHC used in this study. Never-theless, there are situations in which the relationships among some users with TB and health professionals are fragile and precarious, a fact that has decreased the qual-ity and efficacy of the control actions in the family health strategy. Even though statements showed that the family health strategy favors the construction of bonding , profes-sionals revealed that in practice, there are difficulties and limits to making guidelines and policies that lead the dis-ease control action in the city concrete. Therefore, the study stresses the need for changes that promote and strengthen the relations of FHT/TB patients, and in this manner , con-cretize a care system based on integrality and according to the current health policies, in the routine of PHC services.
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Acknowledgements
Dinalva Soares, with Núcleo de Doenças Endêmicas da Secretaria Estadual de Saúde da Paraíba (The Paraíba State Health Secretary Center for Endemic Diseases), for her support.
Alinete Moreira, with the coordination of the Tuberculosis Control Program in the city of Bayeux in Paraíba, for her support.
18. Santos NR. Organização da atenção à saúde: é necessário
